Epidemiology of bone stress injury in Division I National Collegiate Athletic Association Athletes from 2016 to 2022

OBJECTIVES: To evaluate the incidence of bone stress injuries (BSIs) in college athletes from the USA by sport, sex and location. METHODS: Deidentified injury data for US collegiate athletes were collected from the 2016-2022 seasons using the Pac-12 Health Analytics Program from 33 sports. Included injuries were labelled as 'bone stress injury,' 'stress fracture' or 'stress reaction' and grouped together as BSIs. Incidence rates and incidence proportions were calculated and analysed by sport, sex and location. Rate ratios (RRs) were calculated comparing matched sports. RESULTS: There were 1443 BSIs in 33 190 athlete years of participation, 695 female (63%) and 415 male (37%). BSIs occurred most commonly in the lower extremity (n=1165 times, 81%), followed by axial (n=246, 17%) and upper extremity (n=32, 2%). New injuries accounted for 81% of BSIs, while 19% were recurrent. The overall incidence proportion (average annual risk) of a BSI was 4% but risk varied by sport with women's cross country (14.6%), men's cross country (10.2%), women's gymnastics (9.4%), women's track and field (8.4%), women's basketball (8.1%) and women's rowing (8.0%) having the highest risk. Incidence rates were similar. In sex-matched sports, a higher rate of BSI occurred in women in gymnastics (RR 2.72, 95% CI (1.26 to 7.01)), softball/baseball (RR 2.12, 95% CI (1.23 to 3.67)), basketball (RR 2.10, 95% CI (1.41 to 3.17)), track and field (RR 1.71, 95% CI (1.35 to 2.17)), rowing (RR 1.62, 95% CI (1.13 to 2.39)) and cross country (RR 1.45, 95% CI (1.11 to 1.92)). Most sports had predominantly lower extremity BSIs; however, men's baseball, men's/women's diving, men's golf, men's/women's rowing and men's/women's swimming had primarily axial BSIs. CONCLUSIONS: Women college athletes are at greatest risk of BSI with lower extremity injury most prevalent. Understanding sport-specific patterns and incidence rates of BSIs provides critical insight for shaping future injury prevention strategies.